(a)Introduction. This section establishes the quality
metrics that may be used in the Quality Incentive Payment Program
(QIPP) for nursing facilities (NFs) on or after September 1, 2019.
(b)Definitions. The following definitions apply when
the terms are used in this section. Terms that are used in this and
other sections of this subchapter may be defined in §353.1301
(relating to General Provisions) or §353.1302 (relating to Quality
Incentive Payment Program for Nursing Facilities on or after September
1, 2019) of this subchapter.
(1)Baseline--A NF-specific initial standard used as
a comparison against NF performance in each metric throughout the program
[eligibility] period to determine progress in the
QIPP quality metrics. [For example, for MDS-based measures, the
facility's baselines will be set at the most recently available four-quarter
average for each metric.]
(2)Benchmark--A metric-specific initial standard set
prior to the start of the program [eligibility]
period and used as a comparison against a NF's progress throughout
the program [eligibility] period. [For
example, for MDS-based measures, the benchmarks will be set at the
most recently published CMS National Average for each metric.]
(c)Quality metrics. For each program [eligibility
] period, HHSC will designate one or more [of the following]
quality metrics [for each QIPP capitation rate component].
Any quality metric included in QIPP will be evidence-based. HHSC may
modify quality metrics from one program period to the next. The proposed
quality metrics for a program period will be presented to the public
for comment in accordance with subsection (f) of this section.
[(1)Quality assurance and performance
improvement (QAPI) meetings. Monthly meetings in which the NF reviews
its CMS-compliant plan for maintaining and improving safety and quality
in the NF. QAPI meetings must contribute to a NF's ongoing development
of improvement initiatives regarding clinical care, quality of life,
and consumer choice. For the eligibility period beginning September
1, 2019, QAPI meetings have been designated as the quality metric
for Component 1.]
[(2)MDS-based measures. Measures
listed in CMS' Five-Star Quality Rating System and based on Minimum
Data Set (MDS) assessment data. Within the Five-Star Quality Rating
System, HHSC can select any MDS-based measure as long as there are
viable data sources available for timely calculations related to the
measure. For the eligibility period beginning September 1, 2019, the
following five MDS-based measures may be used in Components Three
and Four:]
[(A)high-risk long-stay residents with pressure ulcers;]
[(B)percent of residents who received an antipsychotic
medication (long-stay);]
[(C)percent of residents with decreased independent
mobility;]
[(D)percent of residents with urinary tract infections;
and]
[(E)percent of residents appropriately given the pneumonia
vaccine.]
[(3)Recruitment and retention program.
A program that includes a plan developed by the NF to improve recruitment
and retention of staff and monitor outcomes related thereto. For the
eligibility period beginning September 1, 2019, the recruitment and
retention plan will be used in Component Two.]
[(4)RN staffing metrics. Registered
nurse (RN) hours beyond and non-concurrent with the CMS-mandated eight
hours of RN on-site coverage each day. On-site hours must be met by
an RN, Advanced Practice Registered Nurse (APRN), Nurse Practitioner
(NP), Physician Assistant (PA), or physician (Medical Doctor (MD)
or Doctor of Osteopathic Medicine (DO)). Telehealth services can be
used to meet some or all of the RN staffing metrics when a NF has
telehealth policies and procedures developed in accordance with subsection
(g) of this section. For the eligibility period beginning September
1, 2019, the following two RN staffing metrics will be used in Component
Two:]
[(A)four hours of additional RN coverage per day;
and]
[(B)eight hours of additional RN coverage per day.
A NF that meets the eight hours of additional RN coverage per day
will automatically qualify for the metric described in subparagraph
(A) of this paragraph.]
[(5)Infection control program. A
program that improves antibiotic stewardship and measures outcomes
through the use of infection control and data elements. For the eligibility
period beginning September 1, 2019, the infection control program
will be used in Component Four, and the program will consist of the
following infection control and data elements:]
[(A)whether a facility:]
[(i)has identified leadership individuals for antibiotic
stewardship;]
[(ii)has created written policies on antibiotic prescribing;]
[(iii)has an antibiotic use report generated by a
pharmacy within last 6 months;]
[(iv)audits (monitors and documents) adherence to
hand hygiene (HH);]
[(v)audits (monitors and documents) adherence to personal
protective equipment (PPE) use;]
[(vi)has an infection control coordinator who has
received infection control training;]
[(vii)has infection prevention policies that are evidence-based
and reviewed at least annually;]
[(viii)has a current list of reportable diseases;]
[(ix)knows points of contact at local or state health
departments for assistance;]
[(B)the number of:]
[(i)vaccines administered to residents and employees;]
[(ii)residents with facility acquired Clostridium
difficile diagnosis;]
[(iii)residents on antibiotic medications;]
[(iv)residents with multi-drug resistant organisms;
and]
[(C)select infection rates.]
[(6)Other metrics related to improving
the quality of care for Texas Medicaid NF residents. HHSC may develop
additional metrics for inclusion in QIPP if there is a specific systemic
data-supported quality concern impacting Texas Medicaid NF residents.
Any metric developed for inclusion in QIPP will be evidence-based
and will be presented to the public for comment in accordance with
subsection (e) of this section.]
(d)Performance requirements. For each program [
eligibility] period, HHSC will specify the performance requirements
[requirement that will be] associated with [the]
designated quality metrics. The proposed performance requirements
for a program period will be presented to the public for comment in
accordance with subsection (f) of this section [metric].
Achievement of performance requirements will trigger payments for
the QIPP capitation rate components as described in §353.1302
of this subchapter. [For some quality metrics, achievement is
tested merely on a met versus unmet basis. Other metrics require a
certain level of improvement, such as reaching a quarterly percentage
goal. The following performance requirements are associated with the
quality metrics described in subsection (c) of this section.]
[(1)QAPI meetings. Each month, a
NF must attest on a form designated by HHSC that it convened a QAPI
meeting. The NF must submit the form to HHSC by the first business
day following the end of the month. Each quarter, HHSC will validate
a random sample of the attestation forms. The NF that submitted the
attestation form must provide the supporting documentation stated
in the attestation form.]
[(2)MDS-based measures. A NF must
show a five percent relative improvement on a quarterly basis over
the baseline or exceed the benchmark for the selected measure.]
[(A)Baseline improvement is measured against quarterly
targets determined by HHSC prior to the eligibility period.]
[(B)A NF that exceeds the benchmark for a measure
qualifies for the payment from any related component. A NF that exceeds
the benchmark may decline in performance and still qualify for a payment
from the related component as long as the NF continues to exceed the
benchmark for the measure.]
[(3)Recruitment and retention program.
During the first month of the eligibility period, a NF must submit
its recruitment and retention plan to HHSC. If substantive changes
are made to the recruitment and retention plan, an update of the plan
must be submitted to HHSC during the month in which the changes take
effect.]
[(A)Failure to submit the recruitment and retention
plan in the first month of the eligibility period will result in not
meeting the metric for that month for the related component.]
[(B)Each subsequent month, a NF will submit to HHSC
documentation produced during the development of self-direct staffing
goals and in the monitoring of staffing outcomes, in accordance with
the NF's recruitment and retention plan.]
[(C)Each quarter, HHSC will validate a random sample
of recruitment and retention plans and outcome monitoring documentation.
The NF that submitted the plan must provide supporting documentation,
including policies and outcomes.]
[(4)RN staffing metrics. A NF meets
the RN staffing metrics by showing that the facility was staffed at
the required number of hours for at least 90 percent of the days in
the reporting period.]
[(5)Infection control program. Each
quarter, a NF must report:]
[(A)the presence of a number of infection control
elements to exceed a quarterly benchmark. For the eligibility period
beginning September 1, 2019, the NF must report the presence of seven
of the nine elements in subsection (c)(5)(A) of this section to meet
the metric; and]
[(B)all required data elements regarding infection
control tracking in subsection (c)(5)(B) and (C) of this section.]
[(6)Other metrics related to improving
the quality of care for Texas Medicaid NF residents. If HHSC develops
additional metrics for inclusion in QIPP, the associated performance
requirements will be presented to the public for comment in accordance
with subsection (e) of this section.]
(e)Quality assurance. All data and
documentation supplied to HHSC by the NF to demonstrate achievement
of performance requirements is subject to validation and audit. HHSC
will select a random, representative sample of participating NFs for
quality assurance review each program period and will conduct reviews
on one-fourth of the total sample each program quarter.
(1)If selected, the NF will have 14 business days
from the date of the request from HHSC to submit to HHSC the required
data and documentation.
(2)If the selected NF fails to participate in the
review or to provide the required data or documentation, any payments
to the provider for the quality metric or component under review may
be considered an Overpayment and subject to recoupment or adjustment
as described in §353.1301(k) of this subchapter.
(f)[(e)] Notice and hearing.
(1)HHSC will publish notice of the proposed metrics
and their associated performance requirements no later than December
1 [31] of the calendar year that precedes the first
month of the program [eligibility] period. The
notice must be published either by publication on HHSC's Internet
web site or in the Texas Register. The
notice required under this section will include the following:
(A)instructions for interested parties to submit written
comments to the HHSC regarding the proposed metrics and performance
requirements; and
(B)the date, time, and location of a public hearing.
(2)Written comments will be accepted within 15 business
days of publication. There will also be a public hearing within that
15-day period to allow interested persons to present comments on the
proposed metrics and performance requirements.
(g)[(f)] Quality metric
publication. Final quality metrics and performance requirements
will be provided through the QIPP webpage on HHSC's website on or
before February 1 of the calendar year that also contains the first
month of the program [eligibility] period.
[(g)Telehealth. In order for a NF
to use telehealth services to meet some or all of the RN staffing
metric, the following requirements must be met:]
[(1)the telehealth services must be both audio and
visual in nature;]
[(2)the telehealth services must be provided by an
RN, APRN, NP, PA, or physician (MD or DO); and]
[(3)The NF must have policies and procedures for such
services. The NF's policy must include the following:]
[(A)how the NF arranges telehealth services;]
[(B)how the NF trains staff regarding the availability
of services, implementation of services, and expectations for the
use of these services; and]
[(C)how the NF documents telehealth services including
initiation of services, the services provided, and the outcome of
services.]
The agency certifies that legal counsel
has reviewed the proposal and found it to be within the state agency's
legal authority to adopt.
Filed with the Office
of the Secretary of State on May 14, 2021
TRD-202101946 Karen Ray
Chief Counsel
Texas Health and Human Services Commission
Earliest possible date of adoption: June 27, 2021
For further
information, please call: (512) 424-6637
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